Post‐Procedural Troponin Elevation and Clinical Outcomes Following Transcatheter Aortic Valve Implantation

Abstract

BackgroundBiomarkers of myocardial injury increase frequently during transcatheter aortic valve implantation (TAVI). The impact of postprocedural cardiac troponin (cTn) elevation on short‐term outcomes remains controversial, and the association with long‐term prognosis is unknown.Methods and ResultsWe evaluated 577 consecutive patients with severe aortic stenosis treated with TAVI between 2007 and 2012. Myocardial injury, defined according to the Valve Academic Research Consortium (VARC)‐2 as post‐TAVI cardiac troponin T (cTnT) >15× the upper limit of normal, occurred in 338 patients (58.1%). In multivariate analyses, myocardial injury was associated with higher risk of all‐cause mortality at 30 days (adjusted hazard ratio [HR], 8.77; 95% CI, 2.07–37.12; P=0.003) and remained a significant predictor at 2 years (adjusted HR, 1.98; 95% CI, 1.36–2.88; P<0.001). Higher cTnT cutoffs did not add incremental predictive value compared with the VARC‐2–defined cutoff. Whereas myocardial injury occurred more frequently in patients with versus without coronary artery disease (CAD), the relative impact of cTnT elevation on 2‐year mortality did not differ between patients without CAD (adjusted HR, 2.59; 95% CI, 1.27–5.26; P=0.009) and those with CAD (adjusted HR, 1.71; 95% CI, 1.10–2.65; P=0.018; P for interaction=0.24). Mortality rates at 2 years were lowest in patients without CAD and no myocardial injury (11.6%) and highest in patients with complex CAD (SYNTAX score >22) and myocardial injury (41.1%).Conclusions VARC‐2–defined cTnT elevation emerged as a strong, independent predictor of 30‐day mortality and remained a modest, but significant, predictor throughout 2 years post‐TAVI. The prognostic value of cTnT elevation was modified by the presence and complexity of underlying CAD with highest mortality risk observed in patients combining SYNTAX score >22 and evidence of myocardial injury.

Myocardial Injury Post Transcatheter Aortic Valve Implantation Comparing Mechanically Expanded Versus Self-Expandable Versus Balloon-Expandable Valves

“…3,12 There are several studies to show that new pacemaker implantation, as well as myocardial injury, are associated with worse outcome. [3][4][5][6]22 In our study, there was no association between myocardial injury and 30-day mortality. One can only speculate on how the finding of less myocardial injury would compare to the higher incidence of new conduction disorders in terms of long-term survival.…”

“…cardiac biomarker rise) after TAVI is frequent and may predict the outcome. [3][4][5][6] The exact patho-mechanism of myocardial injury is not clear yet, however several studies hypothesize that factors such as global myocardial ischemia due to balloon valvuloplasty, acute aortic regurgitation, rapid pacing-induced hypotension, micro-embolization of aortic valve debris in the coronary arteries, myocardial tissue compression by the expansion of the device and coronary obstruction should be considered as potential mechanisms for myocardial injury. 3,[7][8][9][10] We hypothesize that prosthesis expansion mechanism may also affect the occurrence of myocardial injury.…”

Impact of post-dilatation on the reduction of paravalvular leak and mortality after transcatheter aortic valve implantation

“…For instance, the presence of coronary artery disease and the occurence periprocedural ischaemic complications may worsen clinical outcomes [21,22]. Another potential factor is the presence of PVL after TAVI.…”

Management strategies for severe aortic stenosis and coronary artery disease in the transcatheter aortic valve implantation era

“…To overcome this lack of consensus, a group of international experts have issued Valve Academic Research Consortium (VARC) consensus statements . These standardized definitions have rapidly been adopted and utilized in contemporary research studies and will help to define the true incidence of MI in future work .…”

“…While the presence of non‐revascularized CAD in patients undergoing TAVI may increase the risk of cardiac ischemia during the procedure, there are limited data to provide information on the magnitude of the risk and no consensus on what constitutes “prognostic” CAD in this context. In a recent study of 577 TAVI patients (64% with CAD), 338 (58.1%) patients had VARC‐2 defined myocardial injury (post TAVI cardiac troponin T (cTnT) >15 × the upper limit of normal) . Myocardial injury was noted to be a predictor of increased 30 day (adjusted hazard ratio [HR], 8.77; 95% CI, 2.07–37.12; P = 0.003) and 2 years (adjusted HR, 1.98; 95% CI, 1.36–2.88; P < 0.001) all‐cause mortality.…”